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S—N JOAQJIN COUNTY PUBLIC HEAL_r_ SER` <br /> EN7VIRONMENTZt ..EP-`_.. DI'.__._0•- <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New_,�Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME �� <br /> V :1�;f f�c..�•_4 111. 5J <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS <br /> ite Mitigation: Y- nvironmental Assessment ST/CAP ocaI Hazardous Waste Invest azMat Pipeline Invest <br /> kher Lead Agency Site �gency: OWQCB DTSC F <br /> EPA PL Site ater Quality Site Other Type Site <br /> DESIGNATED EMPLOYEE # C,( 4 i PROGRAM ELEMENT <br /> f f J t + CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Dace: <br /> AUTHORIZATION TO RELEASE INFORMATION: Ln addition to the above, when applicable, 1, owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E1,77IRONMENTAT_. HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current j prior <br /> I <br /> Fee Amount Amount Paid Date of Payment I Payment Type I Receipt # I Check # I Recvd By <br />